Potential Benefits of Increased Access to Doula Support During Childbirth

Published Online: August 28, 2014
Katy B. Kozhimannil, PhD, MPA; Laura B. Attanasio, BA; Judy Jou, MPH; Lauren K. Joarnt; Pamela J. Johnson, PhD; and Dwenda K. Gjerdingen, MD


The annual costs of US maternity-related hospitalizations exceed $27 billion. Continuous labor support from a trained doula is associated with improved outcomes and potential cost savings. This study aimed to document the relationship between doula support, desire for doula support, and cesarean delivery, distinguishing cesarean deliveries without a definitive medical indication.

Study Design

Retrospective analysis of a nationally representative survey of women who delivered a singleton baby in a US hospital in 2011- 2012 (N = 2400).


Multivariable logistic regression analysis of characteristics associated with doula support and desire for doula support; similar models examine the relationship between doula support, desire for doula support, and 1) any cesarean or 2) nonindicated cesarean.


Six percent of women reported doula care during childbirth. Characteristics associated with desiring but not having doula support were black race (vs white; adjusted odds ratio [AOR] = 1.77; 95% CI,1.03-3.03), and publicly insured or uninsured (vs privately insured; AOR = 1.83, CI, 1.17-2.85; AOR = 2.01, CI, 1.07-3.77, respectively). Doula-supported women had lower odds of cesarean compared without doula support and those who desired but did not have doula support (AOR = 0.41, CI, 0.18-0.96; and AOR = 0.31, CI, 0.13-0.74). The odds of nonindicated cesarean were 80-90%

lower among doula-supported women (AOR= 0.17, CI, 0.07-0.39; and AOR= 0.11, CI, 0.03-0.36).


Women with doula support have lower odds of nonindicated cesareans than those who did not have a doula as well as those who desired but did not have doula support. Increasing awareness of doula care and access to support from a doula may facilitate decreases in nonindicated cesarean rates.

Am J Manag Care. 2014;20(6):e340-e352

Four million infants are born each year in the United States, and the associated healthcare costs are substantial. In 2009, 7.6% of all hospital costs were attributable to maternity and newborn care, totaling over $27 billion.1 Almost half of childbirth-related hospital stays (47%) were covered by private health insurance; 45% of stays were billed to Medicaid programs.1 Maternity and newborn care is the top expenditure category for payments made to hospitals by both public payers and private health insurance companies.2 The average total costs of maternity (prenatal, labor and delivery, and postpartum) and newborn care for commercial payers was $27,866 for a cesarean delivery and $18,329 for a vaginal delivery in 2009.3 While payments by Medicaid programs were less overall, cesareans remain about 50% more costly than vaginal deliveries, at $13,590 for a cesarean delivery and $9131 for a vaginal delivery.3 Ensuring access to evidence-based, high-value care during childbirth is a clinical and financial imperative for healthcare providers, healthcare delivery systems, and health insurers.

A growing evidence base suggests that continuous labor support confers measurable clinical benefits to both mother and baby.4-6 Continuous labor support is the care, guidance, and encouragement provided by those who are with a pregnant woman in labor that aims to support labor physiology and mothers’ feelings of control and participation in decision making during childbirth.4 In a meta-analysis of randomized controlled trials, women who received continuous labor support reported greater satisfaction,7,8 had higher rates of spontaneous vaginal birth,9-11 higher infant Apgar scores,8 shorter labors,7,8 and lower rates of regional anesthesia (eg, epidural labor),12 cesarean deliveries,7,12 and forceps or vacuum deliveries.4,11,13 While many different individuals can and commonly do provide continuous labor support (including obstetric nurses, husbands and partners, close friends, and family members), the strongest results were achieved when continuous labor support was provided by someone who was not part of the woman’s family or social network or employed by the hospital.4

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Issue: August 2014
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